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Overview of Managed Care & Medicaid Changes
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Overview of Managed Care & Medicaid Changes
Medicaid Modernization Stakeholder Group
Staff Training for Transition to Managed Medicaid
IA Health Link
The program aims to bring together all services such as physical health care, behavioral health care, and long term care under one program
Members included in IA Health Link who will be enrolling in Managed Care include:
hawk-i
Medicaid for Employed People with Disabilities or MEPD
Dually eligible Medicaid and Medicare
Low income families and children
Iowa Health and Wellness Plan
Long Term Care
HCBS Waivers
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Programs not Included
Program of All-inclusive care for the elderly (PACE) but they may opt in
Presumptive Eligibility and Retro-active Coverage will continue to be provided as Fee-for-Service through IME
Dental benefits are carved out and will remain the same.
HIPP participants are NOT included in any of the changes related to IA Health Link
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What is a Managed Care Organization (MCO)? Health plan which coordinates care for a
member
Private entity, like other insurance companies
Paid from the State of Iowa to coordinate patient’s care
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What are members doing in January and February? Iowa Medicaid members will:
Receive services from Iowa Medicaid between January 1 - February 29
Receive coverage from their chosen MCO, beginning March 1
All hawk-i members are under UnitedHealthcare and may: Switch to Amerigroup or AmeriHealth; or
Choose to stay with UnitedHealthcare
Members should: Update any address changes with DHS
Watch their mail for MCO member enrollment letters
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What should providers do in January and February? Providers will bill Iowa Medicaid Enterprise
(IME) through the fee for service model
Programs such as Meridian, Magellan are no longer effective after January 1
After March 1, proceed with new MCO pay codes
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Who are the three Managed Care Organizations (MCOs)? 1) Amerigroup Iowa, Inc.
2) AmeriHealth Caritas Iowa, Inc.
3) UnitedHealthcare Plan of the River Valley, Inc.
WellCare is no longer an option
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Will benefits change or stay the same? Benefits will stay the same
Each MCO company can offer “value added services” (additional incentives)
The Managed Care Ombudsman’s Office serves as member advocate Call (866) 236-1430
Email ManagedCareOmbudsman@iowa.gov
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Will DHS continue to determine eligibility? Yes. DHS will determine eligibility at
application
Members will continue to receive a Medicaid card
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Iowa Medicaid Member Services:
1 (800) 338-8366
(515) 256-4606
www.IAHealthLink.gov
IMEMemberServices@dhs.state.ia.us
What is the correct date(s) for how long members can see providers outside of the MCO network and receive 100% reimbursement? And then 90%?
Out-of-network providers will receive full in network reimbursement until March 31, 2016. After that, out-of-network providers will receive 90 percent reimbursement rates indefinitely
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If a member’s provider is not included in their MCOs network, and they see them after March 31, 2016, will the provider be paid? If not, will the member be forced to pay out of pocket? The provider may accept the 90 percent out-
of-network rate from the MCO, or refuse to see the patient.
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If a member of IA Health Link sees a provider who is a registered Fee-For-Service provider with IME, but not signed with any MCO and not willing to work with the MCOs, will the state pay? No, the state will not pay
The provider may accept the 90 percent out-of-network rate from the member’s MCO, or refuse to see the member
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Can patients be billed from providers who are not participating with the MCOs or Medicaid?
Yes. The provider must notify the member that they will pay out of pocket prior to services, or the provider may refuse to see the patient.
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Can patients change their MCO?
Members will be auto-assigned to an MCO
February 17, 2016 deadline to select different MCO for effective date of March 1
May 18 deadline to change MCO for any reason
After May 18th, patients need “good cause”: Example: provider not enrolled with an MCO
Change may take 1+ months
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More Information about Medicaid Program Changes
Sign up for email alerts at IMECommunications@dhs.state.ia.us with:
Subject line: “subscribe”
Include your name, organization and email address
Online resources: www.IAHealthLink.gov
IA Health Link: Medicaid Program Changes Member Services - Iowa Medicaid Enterprise: https://dhs.iowa.gov/sites/default/files/IA_Health_Link_MedicaidProgramChanges.pdf
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Overview of Managed Care & Medicaid Changes
Check your understanding
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Lifelonglinks is the name of the new program launching March 1st.
True or False
False Overview of Managed Care & Medicaid Changes
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HIPP program members will be included in the changes to Managed Care.
True or False
False Overview of Managed Care & Medicaid Changes
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hawk-i Members will be included in the changes to Managed Care.
True or False
True Overview of Managed Care & Medicaid Changes
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The MCO is operated by the State of Iowa.
True or False
False
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Wellcare is one of the Managed Care Organizations.
True or False
False
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Benefits will stay the same under the Managed Care model.
True or False
True
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DHS will continue to manage Medicaid applications and determine eligibility.
True or False
True
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Once assigned, patients are not able to change MCOs.
True or False
False
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What should members think about in making their MCO choice? Are their providers part of the MCO network?
Are their pharmacies part of the MCO network?
Are their health care specialists part of the MCO network?
Does the MCO have any value-added services or health programs that are beneficial?
Does the MCO have member support available to fit their needs (24/7 call center, language support, etc.)?
Phone Call Scenario – 1st caller 26
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Phone Call Scenario – 2nd caller 27
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In-Office Scenario 28
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Guidelines for Providers
Strict prohibitions against patient steering
Inform patients of all health plans in which a provider participates
Disclosure of health plan participation must be all or nothing
Display signage, as provided by the MCO, must include all plans in which they participate
Providers participating in only one plan may display signage for that plan and advise patients that is the only plan accepted by that provider
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Guidelines for Providers
Providers may not recommend one health plan over another, nor offer patient incentives for enrollment
Providers may not assist a patient in the selection of a specific health plan Patients may not use the provider’s fax, office
phone, computer, etc., to make a selection
Providers are not allowed to change a member’s health plan or request reassignment on a member’s behalf
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Primary Care Physician Assignments An additional packet will follow that includes the
member handbook and additional member materials
Members should be aware they will be auto-assigned to a PCP
The PCP will be listed on the front of the card
Members should be aware of their PCP assignment and understand they are able to make a change to another provider as needed.
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MCO General Information:
Check insurance IDs. Each patient receiving Medicaid will present two IDs:
MCO identification card
Medicaid identification card
Check eligibility on IME Website
Eligibility and patient’s MCO will be on IME website
IME website will not provide patient’s MCO ID number
Check eligibility and PCP – each MCO has a provider contact number to call:
Ensure eligibility
Ensure primary care physician
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General Information
Key Contact Information
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IDs and Checking Eligibility
Amerigroup Identification – Amerigroup ID, IA Health Link ID, Name and phone number of
primary medical group
Checking eligibility may be done the day prior: 1) Call Provider Services at 1-800-454-3730 2) Provide NPI number, patient’s first and last name and
DOB 3) If patient’s identification number is unknown, provide:
Your name, first initial of your last name, member’s first and last name, DOB, Medicaid number, SSN, full mailing address, member’s phone number
4) The representative will provide you with the ID number (if unknown), the name of the primary medical group (otherwise known as PCP)
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Changing PCPs
Primary Care Provider (PCP) Assignments are made via NPI Number
If your office is not the PCP then patients will need support changing their PCP
Staff may help a patient by calling the following: 1) Call Provider Services at 1-800-454-3730
2) Provide the NPI number, patient’s first and last name and DOB
3) Have the patient indicate that they need to “Change their PCP”
4) The representative will complete this and provide same day confirmation number; the patient will receive new cards indicating your office as PCP within 10 business days. This change should be effective immediately.
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Key Contact Information
Provider Services: 1-800-454-3730 Member Services: 1-800-600-4441 Amerigroup on Call: 1-866-864-2544 1-866-864-2545 (Spanish)
Precertification: Phone: 1-800-454-3730 Fax: 1-800-964-3627
Pharmacy prior authorization: Phone: 1-855-712-0104
Fax: 1-800-601-4829
Paper claims submission: Amerigroup Iowa, Inc. Claims
P.O. Box 61010 Virginia Beach, VA 23466-1010
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Website: providers.amerigroup.com/ia
Electronic claims submission:
Availity: payer ID 26375
Emdeon: payer ID 27514
Capario: payer ID 28804
Smart Data Solutions: payer ID 81273
Amerigroup Link for Members myamerigroup.com/ia
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General Information
Key Contact Information
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IDs and Checking Eligibility
AmeriHealth Caritas Identification
AmeriHealth Caritas ID, IA Health Link ID, the member’s name, DOB, copay amount, effective date, and member’s primary care provider
Checking eligibility may be done the day prior:
1) Call Provider Services at 515-103-1440
2) Provide the NPI number, patient’s first and last name and DOB
3) The representative will provide you with the ID number (if unknown), the name of the primary medical group
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Changing PCP
Primary Care Provider (PCP) Assignments are made via NPI Number
If your office is not the PCP then patients will need support changing their PCP
Staff may help a patient by calling the following: 1) Call Member Services at 1-855-332-2440
2) Patient will need to provide their identification number, patient’s first and last name, and DOB
3) Have the patient indicate that they need to “Change their PCP”
4) The representative will complete this and provide same day confirmation by providing the representative’s name and date of the call; the patient will receive new cards indicating your office is PCP within 7-10 business days. The PCP change is effective immediately.
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Key Contact Information
Provider Services: 844-411-0579
Member Services: 855-332-2440
Nurse Call-line: 855-216-6065
Website: www.amerihealthcaritasia.com
Electronic claims: • EDI Payer ID#: 77075 • Or Emdeon at
877-363-3666 www.emdeon.com
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UPaper Claims: AmeriHealth Caritas Iowa Attn: Claims Processing Department P.O. Box 7113 London, KY 40742
Utilization Management: 1-844-411-0604 Fax: 1-844-211-0972 Hours: 8:30 a.m. to 5:30 p.m. M-F
Care Coordination/Rapid Response: 1-855-332-2440, prompt 3 Fax: 1-844-399-0477
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General Information
Key Contact Information
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IDs and Checking Eligibility
UnitedHealthcare Identification
UnitedHealthcare ID, member’s name, DOB, primary care provider, & Medicaid type indicated in lower right hand corner
Checking eligibility may be done the day prior:
1) Call Provider Services at 1-888-650-3462 (automated)
2) Provide the tax identification & indicate “claims and eligibility”
3) They will ask if the results should be provided via phone or fax
4) Enter the identification by entering ID number or DOB. If the ID number is unknown then enter SSN
5) The automated system will provide eligibility status, effective date, but will NOT provide PCP
6) In order to obtain PCP, stay on the line and say “representative”
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Changing PCP
Primary Care Provider (PCP) Assignment are made via NPI Number
If your office is NOT the PCP then patients will need support changing their PCP
Staff may help a patient by calling the following: 1) Call Member Services at 1-800-464-9484
2) Patient will need to provide their identification number, patient’s first and last name, and DOB
3) Have the patient indicate that they need to “Change their PCP”
4) The representative will complete this and provide same day confirmation if requested. The patient will receive new cards indicating your office as PCP within 7-10 business days. The PCP change is effective immediately.
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Key Contact Information
Provider Services: 888-650-3462
Member Services: 800-464-9484 M – F 7:30 a.m. to 6:00 p.m. CT
Electronic Claims: UnitedHealthcareOnline.com <secure logon> Claims & Payments Payer ID: 87726
Paper Claims: United Healthcare Community Claims P.O. Box 5220 Kingston, NY 12402-5220
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Prior Authorization Requests:
888-650-3462 Fax: 888-899-1680
Website: www. UnitedHealthcareOnline.com
Prescription Drug Prior Authorization Request Form fax to 866-940-7328
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Member and Provider Handouts
Primary Care Provider Handout – to help patients understand importance of establishing PCP
Member Sample Card Handout – Can be used when patients show up without MCO cards Front side has sample member cards Backside includes contacts for who
to call for help
Provider Sample Card Handout – indicates where to find needed information on MCO Member Cards
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Check your understanding
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Patients need to bring only their Medicaid card to appointments.
True or False
False Overview of Managed Care & Medicaid Changes
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The IME website will indicate eligibility.
True or False
True Overview of Managed Care & Medicaid Changes
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The IME website will not provide the patient’s MCO identification number.
True or False
True Overview of Managed Care & Medicaid Changes
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Patients can be told which MCO they should pick by a case manager, provider or other health care staff.
True or False
False
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Patients who have not received an MCO card are not able to seek care.
True or False
False
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Aging Advocates
Orchard Place
Managed Care Ombudsman Office
United Way
Iowa Medicaid Enterprise
Department of Human Services
Mid Iowa Health Foundation
Children and Family Policy Center
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Broadlawns
Unity Point
Blank Children’s Hospital
Mercy Hospital
Primary Health Care
US Committee for Refugees and Immigrants
Polk County Health Department
Polk County Health Services
Visiting Nurse Services of Iowa
Medicaid Modernization Stakeholder Group
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